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licensed subcontractors and the number of structures does not exceed four within any calendar years, or all of the work is <br />performed under contract with a Iicensed general building Contractor. <br />R ( A. t understand as an Owner-Builder if I sell the property for which this perm it is issued, I may be held liable for any <br />financial or personal injuries sustained by any subsequent owne(s) that result from any latent construction defects in the <br />workmanship or materials. <br />l?-/ S. I understand I may obtain more information regarding my obligations as an "employer" from the lnternal Revenue <br />Service, the United States Small Business Administration, the California Department of Benefit Payments, and the <br />California Division of lndustrial Accidents. I also understand I may contact the California Contractors' State License Board <br />(CSLB) at 1-800-321-CSLB (2752) or Wvvw.cslb.ca.oov for more information about licensed contractors. <br />10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am <br />the party legally and financially <br />address: 4ol,; 'qdab responsibl e for plopos ed construction activ ity at the following <br />270*/"i- <br />K/, r .l agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by <br />all applicable laws and requirements that govern Owner-Builders as well as employers. <br />Lt p.lagree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the <br />information I have provided on this form. <br />Licensed contractors are regulated by laws designed to protect the public. lf you contract with someone who does not <br />have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain <br />as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. lt is also important for <br />you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your <br />property, you may be held liable for damages. lf you obtain a permit as Owner-Builder and wish to hire Contactors, you will <br />be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' <br />com pensation insurance coverage. <br />Before a building permit can be issued, this form must be completed and signed by the property owner and <br />returned to the agency responsible for issuing the p ermit. /Vo(ei A coDv of the proDertv owner's driver's license. <br />form notarization, or other verification acceptable to the agency is resuired tg be plesented wheLlhelelnjljs <br />issued to verifu the proDertv owner's siqnature. <br />Signature of Property Owner ,4*,/oJ 2+^z Date e-/79/ t r <br />Print name of Owner R;.Lor,(. Fotn,- <br />AUTHORIZATION OF AGENT TO ACT ON PROPERry OWNER'S BEHALF <br />Excluding the Notice to Property Owner, the execulion of which I understand is my personal responsibility, I hereby authorize the <br />following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my <br />project. <br />Scope of Construction Project (or Description of Work) <br />Name of Authorized Agent: <br />Address of Authorized Agent <br />I declare under penalty of perjury that I am the property owner for the address listed above and I personally fllled out the above <br />information and certify its accuracy. <br />Property Owner's Signature Date <br />Print Name of Owner <br />Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to <br />be presented when the permit is issued to verify lhe property owner's signature. <br />pr .r yr,)f i.':. r.lnirrr 'tr/l.3. tr,i: : il:) r{,1. p,.t)-,i i,,::. ..::, ,t. 1..,t. <br />SANTA ANA CITY COUNCIL <br />mouhdo@sanla-ana.oro <br />I\' che e Marl nez <br />Mayor Pro Tem Ward 2 <br />mlma.l nei6sanla-ana oro <br />V'cenle Samienlo <br />vsarmienrorAsenla-ana.o.o vrlleoas@sanraanaoro slr.aero@santa-ana.oro <br />Project Location or Address: _ <br />Phone Number of Authorized Agent: <br />lso oio@santa-a.a.oro <br />P Dav d Benavdes <br />dbenavdes@santa ana oro